Endocrine Abstracts

Introduction: Pseudo-Cushing’s syndromes are a heterogeneous group of disorders and include alcoholism, obesity, anorexia nervosa (AN), depression and intense physical exercise. These share biochemical features of Cushing’s syndrome (CS) causing ACTH-dependent hypercortisolism. Distorted body image is a prominent feature of eating disorders. We describe the case of patient with AN who was convinced she had CS. This led to investigations that confirmed hypercortisolism which perpetuated anxiety about an underlying endocrine condition.

Case Study: A 37-year-old woman with a prior history of AN was referred with concerns about facial swelling and elevated random cortisol levels. Investigations showed raised free cortisol excretion and non-suppression on dexamethasone testing. On examination, she was underweight (BMI 17.50) with no features of CS. Facial puffiness in the region of the parotid glands was noted which is well recognised with eating disorders. A history of daily intense prolonged physical exercise was elicited. Pituitary and adrenal imaging were normal. Pseudo-Cushing’s syndrome secondary to AN and intense physical exercise was diagnosed. The patient was asked to reduce exercise and aim for an ideal body weight of 53 kg.

Discussion: Pseudo-Cushing’s syndrome is due to physiologic overactivity of the HPA axis. Mechanisms include reduced cortisol clearance, changes in CBG affinity and glucocorticoid resistance. The latter explains hypercortisolism and lack of clinical signs of cortisol excess in underweight women. This case highlights that performing endocrine tests for ‘reassurance’ and exclusion may be counterproductive as this perpetuates anxiety in already psychologically vulnerable individuals when spurious abnormal results are found. This leads to unnecessary additional investigations. The patient’s perception of facial puffiness was disproportionate to clinical findings and indicated body dysmorphia. Treatment of underlying causes ameliorates biochemical abnormalities. However, body dysmorphia may pose barriers and patients’ may not always be receptive to this. Psychological support remains the mainstay of therapy.